Provider Demographics
NPI:1063783728
Name:DR. PAULA M. NORDSTROM, LLC
Entity type:Organization
Organization Name:DR. PAULA M. NORDSTROM, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:PAULA
Authorized Official - Middle Name:MICHELLE
Authorized Official - Last Name:NORDSTROM
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:208-989-1686
Mailing Address - Street 1:3904 E FLAMINGO AVENUE
Mailing Address - Street 2:200
Mailing Address - City:NAMPA
Mailing Address - State:ID
Mailing Address - Zip Code:83687-3102
Mailing Address - Country:US
Mailing Address - Phone:208-089-1888
Mailing Address - Fax:208-839-2301
Practice Address - Street 1:3904 E FLAMINGO AVENUE
Practice Address - Street 2:200
Practice Address - City:NAMPA
Practice Address - State:ID
Practice Address - Zip Code:83687-3102
Practice Address - Country:US
Practice Address - Phone:208-089-1888
Practice Address - Fax:208-839-2301
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-25
Last Update Date:2019-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPSY-303103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty